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Full text of "Demonstration of an integrated data system to promote cost containment among primary care physicians : executive summary"

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GRANT #18-97538 

SPONSORHSIP: This research was funded in part by the Health Care Financing 
Administration, Grant #18-97538, the Primary Care Research 
and Demonstration Project, Grant #01-0-000214, the W.K. 
Kellogg Foundation, Grant #79-11,. and the Robert Wood Johnson 
Foundation, Grant =5215. 

The information enclosed does not necessarily reflect the policies of any of 
the above-named grantors. 





I. Introduction : 

The Primary Care Cooperative Information Project has worked for the 
past five years to integrate the interests of comniunity physicians, medical 
school faculty, and health policymakers in the areas of computerized medi- 
cal information systems, practice management, quality assurance, cost- 
effectiveness research, and education. A few of the major accomplishments 
■ of the past year were: (1) selection of a new computerized data system, 
(2) development. of a system of management audits to improve management 
efficiency, (3) revisions of monthly, quarterly, and year-end feedback 
reports, (4) completion of a research project on patient functional health 
status and initiation of prospective studies on fatigue and smoking, 
(5) improvement and expansion of the cost-consciousness education program 
for medical students, (6) publication of several papers on the COOP Project, 
and 0) presentations Oii work done by the COOP at nauiu.ial .neetings. 

The major problem encountered this past year was the unexpected loss 
of federal funds that had been awarded to assist in starting the COOP 
Project. The progress made towards reaching COOP objectives, in light of 
the major changes brought about by the loss of funds, are summarized below: 

II. Medical Information System : 

The central element in achieving the goals and objectives of the COOP 
Project is the Medical Information System (MIS) and the Cross-Practice 
Data Base. The MIS is constructed as an integral part of each practice's 
patient encounter, billing, accounts receivable, and general ledger system. 

one of the services that the COC? provides its participating pract.ces 
is the ability to respond to specific C=ta requests. During the past 
year, there were 26 requests for special data reports which included 47 
health centers. The COOP also markets Superbills to non-CCOP practices 

in Vermont and New Hampshire. 

initially, the collection of the r.inimum data set was designed in 
such a way that the data would be entered into a computer located at 
Dartmouth Medical School. This is called the batch-and-n,ai 1 syste.. The 
second phase was to design a .ini -computer office-based computer system. 
When fully designed, this office based computer system will be able to 
achieve all of the necessary accounting functions for the practices, as 
well as to provide the COOP with its minimum data set. This will be 
stored In the Cross Practice Data Base. 

in o.r efforts to determine the most efficient and effective hardware/ 
software systems available, the COOP completed a two-year evaluation of 
the experiment with the Data.edic System. The evaluation concluded that 
there were no real dollar savings in thP Datamedic approach. It was our . 
conclusion that a microcomputer tied to a central computer was not the 
most cost-effective way to proceed with computerization within small 
practices. Our efforts were, therefore, directed at finding true stand- 
alone mini -computers which would be office-based. 

Our initial recor^endation was a software package produced by 
Professional Business Systems in San Francisco. California, called "Softca^e" 
which was running on an Apple 11 computer. However, due to problems 
encountered with the software, this selection had to be negated and our 

= tWP •■■o-'ical Offic- "anagement System (MOMS) produced 
final selection was the r.euicai jm .c- a 

^,.1 ^f raiHfnrnia which runs on an Altos 
by Health Data Products, Incorporated of California 

computer. The COOP agreed to buy tacv the Apple computers from the 
practices at no cost to the practice. In turn, these Apple computers 
were sold to individuals in the privare marketplace. The MOMS System 
was modified slightly to m.eet COOP specifications and was implem,ented 
on September 1 , 1982. 

As of January 1, 1982, practices now have two options with respect 
to submission of encounter data. First, they can use their own computer 
(microcomputer system) to enter encounter data and perform other tasks 
such as billing and accounts receivable, general ledger, patient call- 
backs, etc. They are responsible for^purchasing the hardware, and COOP 
funds are used to provide needed software for each system and to pro- 
duce feedback reports and special cross-practice analyses. Or, they can 
continue to use the batch-and-mail (manual system) to submit encounter 
data. The practices are responsbile for purchasing this service from .. 
the COOP at a charge of 38(t per encounter form. The changes in the MIS 
were made to: (1) shift the costs of encounter form data entry from COOP 
gr?iit v,utuort to prartV.e sel^-paymeit; and (2) stimulate quicker develop- 
ment of a more powerful and cost-effective microcomputer-based, distributed 

data system.. ; ■■•.'■■ • 

During the coming year, the COOP will continue to: (1) support the 
batch-and-mail system, (2) refine as necessary the monthly, quarterly, 
and annual reports, (3) respond to data requests from COOP practices. 
(4) market the Superbill, and (5) implement the new MOMS/Altos system in 
a number of COOP practices. 

III. Practice Management : 

Practice management consultation is one of the services which the 
COOP provides to its member practices. The activities in the areas of 

practice ManagefP.ent have been divided into two principle areas -- reactive 
activities and proactive activities. The central goal is to assist prac- 
tices in achieving efficient and cost-effective operations for the 
delivery of health care. 

The COOP decided that it needed to develop a more structured approach 
to management consulting. Accordingly, the concept of the management 
audit was developed and implemented during 1981-82. Management audit is 
defined as methodical examination of whether or not management is truly 
accomplishing planned goals and objectives. There are three basic objec- 
tives to the management audit: {]) efficiency, (2) economy, and 
(3) effectiveness. Application of these basic objectives can significantly 
aid the practice in knowing where it is, where it wants to go, and how to 
get there. 

Beginning January 1, 1982, the COOP began scheduling two management 
audits per year to provide structured, systematic consultation. All 
management assistance beyond that point will be performed on a fee-for- 
service basis at a cost of $60 per visit payable by the practice. The 
changes in Practice Management were intended to: (1) ensure that all 
practices receive systematic assistance, and (2) prepare the way for 
making management services self-supporting in the future, 

IV. Quality Assurance : 

The COOP Project aims to help physicians provide better health care 
at lower cost. Because of the significant cutbacks in COOP funding, 
especially in the area of Quality Assurance, an important strategy for 
reaching this aim is to foster the development of voluntary quality 
assurance systems within practices that are in the COOP. 


The first r.ajor quality assurance accompl ishinent was conipletion of 
a cross-practice study on the costs and effects of weight loss treatrr^ent 
provided by four different COOP practices. The second major quality 
assurance accornpl ishrrent was a redirection of our thinking in the face 
of resource limitations and relative dissatisfaction with our success in 
the past. 

The quality assurance objectives for the year ahead are to: (1) continue 
to feedback quality assurance-related data to all COOP practices; (2) con- 
tinue to provide technical assistance to practices on their request; and 
(3) refine the data system to provjde more reliable information in the 
area of quality assurance. 

V. Clinical Cost-Effectiveness Research : 

An objective of the COOP Project is to conduct practical research on 
relevant primary care topics to assess the costs and effects of health 
care delivery. It is believed that our work in clinical cost-effectiveness 
research can produce two benefits. First, the process of participating in 
the design, conduct, and analysis of these research topics may increase 
the interest and awareness of participating physicians in finding economi- 
cal methods of providing effective treatment to their patients. Second, 
publication of the results may contribute to the literature regarding the 
costs and health consequences of primary care and stimulate new networks 
to engage in similar research. In addition to prospective research, the 
Cross Practice Data Base is used to provide physicians with feedback that 
shows their own practices average charges per patient per year compared 
to other COOP practices. This is done to increase COOP physicians' know- 
ledge about hew their pattern of providing care compares with others with 
respect to cost. 


During the past year, three rriajor acconpl ish;'ents were realized: 
(1) Functional Health Status Study: An observational study of more than 
1200 adult patients (N=1227) served by 28 different medical practices 
was planned, implemented, and completed; (2) Fatigue Study: A one-year 
longitudinal study on the functional health status, clinical services, 
and health expenditures of patients bothered by fatigue and a matched 
control group of patients (N=437) was undertaken; and (3) Smoking 
Cessation Study: A one-year controlled intervention study on smoking 
cessation which tests the effectiveness of physician-directed efforts at 
inducing patients to quit cigarette smoking, especially among persons 
with chronic respiratory conditions or at-risk for coronary heart disease 
was implemented.. 

The coming year involves completing the Fatigue Study, continuing 
work on the Smoking Cessation Study, and selecting a new study topic 
for protocol development and implementation. 

V I . Education : 

The COOP sne'cs tc engage in educational activities that can en?ble 
medical students, residents, and practicing physicians to become more know- 
ledgeable about clinical cost-effectiveness, practice management, and how 
computerized medical information systems can improve medical care delivery. 
Education is an integral part of all COOP functions and is delivered in 
multiple ways -- feedback of data, personal consultations, group discussions; 
written material, and participation in COOP activities such as cost- 
effectiveness study protocol development and teaching medical students to 
be cost-consciousness. 

Loss of federal funding requir-ed us to scale back our education 
efforts. The main educational p-Tject was to conduct a cost-awareness 

program for Dartmouth nedical Scrool stuJents as part of their primary 
care clerkship. This education program used information produced by 
the Cross Practice Oata Base and COOP physicians to provide tutorials 
for medical students doing clerkships in their practices. This is the 
second year that this program has been conducted. 

Next year's workplan for education will, of necessity, be modest. 
It involves the Annual Meeting, publication of the Newsletter, and 
improved feedback of information to COOP members from the Cross Practice 
Data Base. 

The Medical School is converting from a three-year to a four-year 
program; therefore, there will be a pause in continued development of 
the medical student cost-consciousness program. VJe will use this oppor- 
tunity to explore the feasibility of seeking new support to develop an 
education program for medical residency programs. The aim would be to 
use the new COOP computer system to teach residents how to: (1) practice 
cost-effective medicine, (2) manage their practices, (3) improve conti- 
nuity of care, (4) establish a quality assurance system, and (5) perform 
practice-based research. This would require development of an educational 
"package" that would include an instructor's guide, resident workbooks 
for each topic, and appropriate computer software. 

VII. Conclusion; 

Much progress has been made in the past five years in developing a 
medical information system that can provide services to the COOP practices 
to open up new opportunities in primary care research, practice management, 
continuing education, and quality assurance. While "he achievements to 
date are real, they have been drastically limited due to cutbacks in 

funding. Plans for the corning ye;rs are to work towards sustaining self- 
sufficiency while carrying out rigorous primary care research and 
delivering medical information and management services that can improve 
patient care and operating efficiency. 

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